Provider Demographics
NPI:1659661288
Name:MCGOWAN, MARK SPENCER (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:SPENCER
Last Name:MCGOWAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MEDICAL DR
Mailing Address - Street 2:A200
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4946
Mailing Address - Country:US
Mailing Address - Phone:801-203-0290
Mailing Address - Fax:
Practice Address - Street 1:415 MEDICAL DR
Practice Address - Street 2:A200
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4946
Practice Address - Country:US
Practice Address - Phone:801-203-0290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-16
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT800879799221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice